Case 4 History ---- This woman was well until age 57 when she had the onset of slurred speech. At age 58, she developed a trouble chewing and swallowing to the point of choking on solid foods and having trouble with liquids. Over the course of two years, she lost approximately 50 lbs. At age 60, she noted progressive decreased strength in her left arm and decreased strength in all her neck muscles. When she was admitted to Barnes Hospital ai· the age of 60, a physical examination showed normal mental status. Both eyes tended to deviate to the right. The patient could not look up or to the left past the midline. The corneal reflexes were normal. There was bilateral peripheral facial nerve weakness. She had decreased gag reflex and poor swallowing. She could not rotate her head or protrude her tongue. The motor exam showed weak arms bilaterally. There was no mention made in the chart of fasciculations. The deep tendon reflexes were all hyperactive and both plantar responses were extensor. She was able to walk, although she had poor tandem gait. At that time she had a gastrostomy inserted. Over the next year, the patient had progressive decrease in her strength and she died at home at the age of 61.
